the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Tuesday, August 04, 2009

weighty issues

usually i try to avoid the sensitive issues. i mean this blog is mainly about entertaining stories. but the next story by its nature forces us to ask some heavy question.

casualties called."bongi, i think you need to come and see this. we have a hippo attack patient.""sure thing. i'm on my way." strangely enough a few years previously i had treated another hippo attack patient so i wasn't totally blown out of the water...so to speak.

i walked in. there were blood soaked bandages on both legs. but she looked too sick to only have leg wounds. besides any self respecting hippo isn't going to merely nibble on its victim's calves a bit. chihuahuas do that. hippos put a bit more oomph into their bite. but the one thing that really stood out in my mind was how overweight the patient was. i groaned. no matter what the injuries obese patients are prone to all the risks associated with surgery, and i'm not even taking about being the hapless chew toy of an animal that is not known for mouth hygiene. lie all day in your own sewerage water and see how clean your teeth are after a few years. i knew this wouldn't be easy.

"wow!" i said, "if the hippo is that badly injured i can only imagine how bad my patient must be." i suppose i couldn't help it. i just needed to find something light hearted in the whole situation. after enduring evil glares from the casualty officer and the sister i approached the patient.

she had massive lacerations in her legs, which i'd need to debride and clean out thoroughly. she also had a large gash on her back. these were all that she was complaining about. it was also all i was consulted about. but as is my habit i checked out the rest of her too. her abdomen was slightly tender, but not too bad. with deep palpation she grimaced. to be honest through all the fat i could feel nothing so i asked for a ct scan.

the scan showed bowel outside the abdomen in the more than spacious subcutaneous tissue. she also had a cracked rib and a mild lung contusion. this case was no longer simply a debridement case but a laparotomy case too.

the operation went well. i learned that it is not a good idea to get chomped by a hippo. one tooth had actually penetrated the abdomen without breaking the skin. but the hippo had managed to deglove almost all the abdominal fat from the abdominal sheath, creating a massive cavity between the fat and sheath. this is where most of her bowel lay, already becoming mottled from strangulation. the pancreas was bruised but ok. the rest of the abdomen was fine.

i sorted out what needed sorting out. i placed drains everywhere i could and closed. as expected, she needed icu admission where she sounded like darth vader for a day or two. then she slowly got better and finally went to the ward.

during this time i spoke to her daughter who was admitted in the orthopaedic ward with a fractured ankle (apparently a hippo had trodden on it). i asked what had happened.

there are guided walks available in the kruger from pretty much all of the camps. you go out with an armed ranger and learn a bit about the bush. you may get to see some wildlife too, but you might want to keep in mind wildlife tends to be, well, wild. these people wandered a bit too close to a pool which had a hippo in who was generally having a bad day. he took exception. he came charging out directly at them. the daughter was in front. she turned to her mother, behind her and screamed,"run!" she then promptly tripped and fell. the hippo came rushing right past her, luckily only stepping on her ankle in its headlong charge and grabbed her mother, my patient, for a quick chew. then, just as quickly as it had started the hippo left.

my first thought was why bother telling someone who is so overweight to run when they clearly can't? a waddle just won't suffice in the face of an oncoming hippo. but more seriously i actually thought what were people like that doing on a walk in the bush? if you go for a walk in the kruger you should at the very least be able to climb a tree and that at high speed. surely they should have a weight limit for these walks?

and that is where the difficulty comes in. the idea that to put a weight limit on something like that is discrimination against the overweight. my mind wanders back to the overweight lady who refused to be told she could not go on a cave guided tour because the weight restriction was supposedly discrimination. they caved in (an occasional pun is good for the soul) and allowed her to go. she got stuck in one of the smaller tunnels. fact is she was too large.

from a medical point of view, obesity is a disease with associated co-morbidities and increased risk of death. there is definitely a much higher risk with any surgery. it is just so. it is. i am not discriminating by stating the facts.

so let me conclude that i am fully in favour of no discrimination against the overweight. but because it is a disease it must be seen as such and not just swept under the rug.

16 comments:

if you go for a walk in the kruger you should at the very least be able to climb a tree and that at high speed. surely they should have a weight limit for these walks?

As a fellow South African and Kruger devotee, I agree with the above. But why would it be discrimation? At theme parks here in the UK (and I believe Disney USA), they have a height limit for some of the rides because it's too dangerous for the kids otherwise. How is a bush walk any different? As you say, "keep in mind wildlife tends to be, well, wild" Ooo, that's dangerous too then isn't it?? Or do we overlook that because suddenly as adults we don't have to watch out?

I had another "discrimination" thought though: If you had a weight limit, shouldn't there be an age limit too? Should the limitation (NOT discrimination) be one of agility rather? i.e. the ability to climb a tree "at high speed" or, if nothing else, just get out of the way damn quick (the latter being mostly impractical in the case of wild animals who can probably run faster than we!).

I find myself asking that if infirm or overweight people go on walks like this, are they risking not only their health and safety, but the safety of the others in the group too? I wonder how many of the others would - if told to flee - turn to help an older/more infirm/overweight person; or would they idly stand by - or sit in their tree - and let that person be attacked? Would human nature incline them to want to help, thereby endangering themselves? Or would sheer selfish desire to survive prevent them?

No, I don't think it's discrimination placing limitations on dangerous activities. It's just practical and sensible. Oh wait, I forgot, common sense is dead and has been survived by political correctness! Ah well, keeps you busy then...

My question is why did the guide not shoot the hippo as soon as it charged, this to me sounds like negligence as he certainly failed to do his job. If he had performed his required duties, there should have been no need for agility.

daffy, good question. i will answer it in general and then specifically for this case.

a hippo, although large, is amazingly fast. to stop one with a single shot at full speed is not quite as easy as that. only a brain shot would have sufficed. any other shot would just have annoyed an already not so happy hippo. the single bullet killing a charging animal is pretty much a hollywood thing. possible but far from probable.

then specifically for this case (yet still for south africa in general). of course it was negligence. this is south africa. that's the way it goes. the armed ranger had no bullets and the radio he had to contact the camp if anyone was to, say, get attacked by a hippo had no batteries. in this country if you choose to put your trust in the guy with the shiny gun and the fancy radio, you might want to reconsider.

all in all, if you go into the african bush, hone your tree climbing skills beforehand. then take a gun too.

having operated all day on bariatrics needing their hips and knees replaced because they have worn them out..........all i can say is; your Job is probably one of the MOST interesting jobs in the world. its all to sterile and boring over here in uk.hope the guard is not in trouble: or the hippo.

orthopod, nothing will happen to him. firstly he was sent out and wasn't ultimately his fault. the system let him and them down.

hippo was acting as hippos do so he would be left alone i think. the lion attack that i posted about previously was hunted down and killed. lions are different. also the two leopard attacks in skukuza were both hunted down and destroyed.

I still believe it negligent. In my experience, even the loud bang associated with a gun going off turns most animals in their tracks from surprise, no matter what they've made their minds up to do.. The ranger shouldn't have gone walking without bullets, I certainly wouldn't if I were him! He's just asking for an injury on duty!

Also, and don't misunderstand me - I'm not defending the overwieght, but I believe just being agile in the african bush just isn't enough.. you dont get much more agile than say an impala, but they get eaten frequently. I think it has more to do with just how lucky you are that day.

I have a story to re-inforce my last point. This comes from a friend who lives on a private game reserve bordering the kruger. A woman of considerable BMI was walking home from work, accompanied by her husband of more normal proportions, riding his bicycle. A lion walked into the road looking for a snack, and thought one of them would do. Both fled (as is a normal reaction under these circumstances). Surprisingly, the woman got away, and the man on his bicycle got caught and eaten. The bicycle seat was also eaten, so I'm not sure the lion chose him over her because it thought he would taste better. He was just unlucky.

daffy, as i said in my first reply to you, and i quote,"of course it was negligence."so we actually agree on this point.

however turning a hippo with a loud bang when it has mayhem on its mind? i think not. bufallo also not easy to turn. in a previous post about a lion attack, the ranger shot the lion's jaw off and it still attacked him. loud noise and missing jaw did not deter it.

yes luck is an important part of surviving the african bush.

but remember there are hundreds of guided walks in the kruger and so to say close to zero attacks (not quite zero but close) so generally the animals will leave people alone. bruce blyden in his book says they actually would walk through the bush making as much noise as possible to advertise to the animals their presence so they could get out of the way.

however i still climbed every tree in my garden after this event to make sure i still could.

Last night at Toastmasters the Joke master told this old joke (in English) 2 guys from the same department at work decided to go hiking. They were having a grand time talking and drinking and kicking rocks over the side of the mountain trail. Then they heard a coughing sound coming down from a higher level, and by the sounds it was coming their way on the same trail. One of the guys said, "It sounds like a bear!" as he was taking off his backpack and digging into the pack. The other feellow said, "What are you doing? WE've got to find an easy tree to climb." The other guy pulled out a pair of track shoes and began putting them on. The first fellow, said, "Hey its no use, a black bear can outrun a horse for a short distance. You'll never outrace the bear." The other fellow looked up and said, "I don't have to outrun the bear, I just have to outrun you."

edoriver, good one. a friend of mine says if you go walking where there are lion, the only weapon you need is a 9mm. if you come across lion, take out your 9mm, shoot your friend in the leg and run like hell.

Daffy: forgive me please if I dont find it at all surprising that the (thin) man in your story got eaten. Perhaps it just proves the point I made in my comment? Did his human nature purposely put himself between the lion and his wife in an effort to protect her, thus giving her the time to get away?

The other thing you have to understand is that this is South AFRICA. Despite my having not lived in her for 20 years, I still remember how it worked back then. Basically it didn't - and they were the good years!! If you've never lived there for a GOODLY LONG TIME (not 5 mins!), you will never understand how she operates. Negligent or not, you simply cannot apply an Outside-of-Africa rule of measure and expect her to come up to scratch. She never will, so you'll only end up irritated. Besides, I must confess that my initial thought about the guard with the gun was that, in true African form, he was the person running the fastest leaving everyone else to fend for themselves.

Anonymous: interesting. I hadn't even considered that being too TALL would disadvantage you. Well well ... oh some PC person's gonna jump on that one; just you wait and see ...

A surgeon once told me that he knew a surgeon who didn't want to operate on anyone over 160lbs. I don't know if he held to that or it was just his ideal. I'm thinking that might seriously limit him in The States.

I would lOVE to see these animals.

We have a lot of black bears in our area. One was up close and personal with our son when he was walking the dog the other night. he yelled real loud to scare it away and it did turn away.

Elephants fascinate me the most. Do you have any elephant stories. And are giraffes friendly?

the idea of a person being eaten alive is so gruesome and disturbing! Do most animals at least go for the jugular for an instant kill or are people just randomly torn apart? And if this is prolonged..does the body go into shock and at least the person doesn't feel it?

seaspray, we'd probably all prefer not to operate on the obese, but most of the time you have no choice. you can't exactly tell them to lose weight as that is very nearly impossible in most cases.

i operated an elephant attack survivor a while ago. he was very lucky. i posted briefly about it under the big five.

girraffes are massive. their hoves are as big as dinner plates. no wild animal is friendly. they are wild. once a girraffe tried to kick my car. he missed but it would have been a mess otherwise.

lions and leopards and cheetahs go for a kill usually. wild dogs eat the animal alive, usually starting from the hind quarters, making for a pretty gruesome and painful death. hyenas also eat alive when they hunt, usually.

I didn't know that and what a gift to be able to see these animals. Conversely.. the trade off is they can hurt you and so i am guessing that for those that live there you all know better and know your boundaries.

What about poisonous snakes? Do you have the kind that can kill you instantly. My husband said that in Vietnam their was a snake they called a 2 step.. because if bitten..2 steps and you're dead.

Are elephants likely to attack? I've heard they are very intelligent. It kills me when I see them chained up at some local fair for everyone to come stair at. I hate it. Once..I held eye contact (so I thought) with an elephant at the fair and I was trying to show compassion and say I cared. silly ..I know. But it is wrong to keep them chained like that ..well I think so anyway.

I've also heard they have good memories and remember when someone has abused them and attack that person.

And the documentaries that show the culling of elephants in India and I think Africa hurt to watch. they have families and they get massacred. And then they've shown that when elephants wonder through an old culling area.. some will stop..pick up a bone in their trunk and walk holding onto it...possibly knowing who that was. :(

There was also a documentary about this guy who lived alone with Kodiac bears in Alaska. It was a dangerous thing to do... but he felt he befriended them, gave them all names and recorded a lot of info. The last season..he ended up staying later then he should have and had to set up camp someplace he didn't usually and he did have an uncomfortable feeling. But at that time of year more bear come through the area.

They weren't out by the water to be picked up when the pilot got there. He got out of the plane, started walking in and had a bad feeling. He flew over head and saw the campsite trashed. Turns out a bear had eaten the guy and his girlfriend and their is an audio of the entire thing..which was never made public as far as I know. They killed the bear and they were in his stomach contents. How gruesome! I wish I didn't know. But.. like you say wild animals..act like wild animals.****************************You said:"no matter what the injuries obese patients are prone to all the risks associated with surgery,"

"from a medical point of view, obesity is a disease with associated co-morbidities and increased risk of death. there is definitely a much higher risk with any surgery. it is just so. it is."

WHY? Why *much* higher? What if they were just heavy but didn't have any co-morbidities?

A couple of years ago Sid wrote that Christmas post about operating on Santa Clause and described the yellow greasy, slippery belly fat that made surgery more difficult.

is that why?

or is just because..the body is being assaulted with surgery..putting stress on it and so it has to use all it's strength to counter that..but if heavy..than the body is already working hard to keep things going? ha! can you tell my medical expertise is zero?

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the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.